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Calling the Shots: Immunization Finance Policies and Practices
PRIVATE-SECTOR ROLES AND RESPONSIBILITIES
As noted earlier, most children receive their immunization services today from a private health care provider. Although the federal and state governments purchase more than half of the childhood vaccines distributed in the United States, private-sector health plans play an equally important role in determining how immunizations are delivered and influence how the costs of vaccine purchase, vaccine administration, and record keeping are distributed across the different levels of the immunization system. Three important concerns deserve attention in considering the roles and responsibilities of the private sector within this system: (1) whether immunization is a covered benefit within primary care health plans offered in the private sector, (2) whether private health plans monitor the immunization coverage levels of their members to determine whether their rates are up to date, and (3) whether private health plans are prepared to take action to improve coverage rates if disparities are found within their membership or their members’ communities.
Immunization as a Covered Benefit
Most but not all private health plans include immunizations, but health plans and insurers do not cover all immunizations fully as a covered benefit. Private plans are more likely to cover immunizations for infants and children than for adults.1 A preliminary draft of the Healthy People 2010 report included a goal of increasing to 90 percent the number of 2-year-old children who receive vaccinations as part of comprehensive primary care (baseline: 66 percent in 1996), which would constitute a 50 percent improvement over the year 2000 objectives (Department of Health and Human Services [DHHS], 1998). To achieve this goal, immunizations must be covered within primary care health plans. But even though earlier health objectives (DHHS, 1999) included a proposal to have all private plans cover immunizations fully as a basic benefit (Objective 20.15), many plans do not do so.2
Coverage of adult vaccines as a benefit within private health plans is highly variable and remains largely undocumented. The Healthy People 2010 objectives include increasing the level of coverage to 90 percent for annual influenza vaccinations (baseline: 63 percent in 1997) and for one-time pneumococcal vaccinations (baseline: 43 percent in 1997) for noninstitutionalized adults aged 65 and older (DHHS, 2000). The 2010 objectives also propose increasing the level of coverage to 60 percent for annual influenza vaccinations (baseline: 25 percent in 1997) and for one-time pneumococcal vaccinations (baseline: 11 percent in 1997) for noninstitutionalized high-risk adults aged 18 to 64. However, no initiative has been